Biologic agents

Biologic agents differ in their effectiveness for controlling specific rheumatic diseases depending on which cytokine is driving the patient’s inflammation.
Tumor necrosis factor inhibitors are more effective when combined with methotrexate.
Interleukin-1 inhibitors are most effective for Crystal Arthropathies, Still’s disease and the cryopyrinopathies.
Risk of hepatitis B reactivation and mycobacterial infections are increased in patients on biologics.
Live vaccines should not be given to patients on biologic agents.

Nomenclature

-cept: receptor drug which prevents a ligand from binding to its receptor (e.g., etanercept, abatacept, rilonacept)

-ximab: chimeric monoclonal antibody (e.g., infliximab, rituximab).

-omab: murine antibody (e.g., Tositumomab)

-zumab: humanized monoclonal antibody (e.g., certilizumab, tocilizumab, eculizumab).

-mumab: fully human monoclonal antibody (e.g., adalimumab, golimumab, belimumab, ustekinumab).

-ra: receptor antagonist (e.g., anakinra).

-tinib: inhibitor (e.g., tofacitinib).

Precautions that should be done before starting any biologic agents:

--> Establish and record disease activity using SCQM.

--> Screen for comorbidities: infection risk, HIV risk factors, hepatitis B/C risk factors, history of malignancy (lymphoma, melanoma, others), history of demyelinating disease, history of tuberculosis (TB), history of fungal exposure, hyperlipidemia, liver disease, pregnancy, medications.

--> Vaccination status: patients should receive inactivated influenza vaccine (seasonal) and age-appropriate pneumococcal, meningococcal, and Haemophilus influenzae B (Hib). Give herpes zoster vaccine (live) at least 2 to 4 weeks before biologic use.

--> Tests before use: complete blood count (CBC), creatinine, hepatic enzymes, lipids, C-reactive protein, hepatitis B and hepatitis C serologies, purified protein derivative (PPD) (or interferon gamma release assay), chest X-ray, HIV (if risk factors).

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